1. Nursing Ethical Issue: Medication Errors Brittany Miller, Katie Poindexter Inna Martynyuk Osipov, Deborah McCray

2. Nursing Ethical Dilemma The following nursing ethical dilemma experienced by a student nurse involved a medication error that took place on a labor and delivery unit. A pregnant patient arrived at the hospital during the night. She was seen in the OB office earlier in the day and was sent to be admitted for a 24-hour observation. The patient’s blood pressure was obtained in the office earlier that day and was found to be extremely high (~230/170).

3. Ethical Dilemma (continued) The client was 26 weeks pregnant at the time and was being treated for hypertension with what she thought had been Labetalol. This medication is a Beta-Blocker and is to be used cautiously during pregnancy as it is a Category C (Deglin & Vallerand, 2009). The home medications list was completed upon the patient’s arrival and sent to the pharmacy. The medication list was accurate as the patient had her medication bottles with her upon admission.

4. Ethical Dilemma(continued) When the list of medications came back up from the pharmacy, the medication listed on it was not Labetalol, but Tegretol. The preceptor and the student nurse discussed the situation and contemplated on whether or not this was indeed a true medication error. Out of curiosity, the student nurse looked up the medication in the drug guide that was available on the floor. As stated by Deglin and Vallerand, Tegretol is an anticonvulsant which has a listed side effect of hypertension. Tegretol is also a Category D for pregnancy which “studies in pregnant women have demonstrated a risk to the fetus” (Deglin & Vallerand, 2009).

5. Ethical Dilemma(continued) After looking up this medication in the drug guide, the student nurse shared her findings with the preceptor and the preceptor promptly asked the student nurse to go ask the patient to see the medication bottle. The student nurse was in the patient’s room at 4 am waking her up to inspect the medication bottle, which immediately was found to be labeled as Tegretol. The preceptor then double-checked the label to make sure the pharmacy medication list was accurate. After the medication error was confirmed, the nurse and student nurse looked through the patient’s chart to see if the error that occurred could be traced.

6. Ethical Dilemma(continued) While looking through the prenatal record, all the proceedings showed that the medication ordered was in fact Labetalol. Even on the patient’s admission papers to the floor, Labetalol was ordered. With this information, the only logical answer could be that the error occurred at the pharmacy. After discovering this error, the preceptor promptly called the on-call doctor to notify her of the error. The doctor gave orders to stop the Tegretol and to order an am dose of Labetalol. The doctor also stated that she would be up there in the morning to inform the patient about the error.

7. Medication Errors: Ethical Standpoint Medication Errors occur more frequently than they should in health care. There are three stages in which medication errors can occur. These stages include: “initial prescribing, medicine dispensing, and administration” (Banning, 2011). According to the Institute of Medicine, it is estimated that at least 1.5 million Americans are sickened, injured, or killed each year by errors in prescribing, dispensing and taking medications (Kaufman, 2006).

8. Drug Errors: Statistics MEDICATIONS REVIEWED WHEN DISCHARGED FROM THE HOSPITAL, AMONG SICKER ADULTS, 2005 US RANKED THE LOWEST Data to displays percent of hospitalized patients with new prescriptions who reported prior medications were reviewed at discharge. According to these statistics, the data clearly illustrates US being ranked the lowest in this area which potentially leads to more drug errors.

9. Drug Errors: Statistics Medical, Medication, and Lab Errors Among Sicker Adults, 2007: Percent reporting medical mistakes, medication errors, or lab errors in the past two years; an international comparison. US reported the highest rates of errors among adults.

10. Legislation for Medication Errors Several introductions of bills related to medication errors have been introduced to Congress. It was not until 2006 that language related to the decrease in medication errors was passed. WHAT CHANGED THE MINDS OF LEGISLATORS? Language was added to HR 6111 Tax Relief and Health Care Act of 2006 (signed into law on December 20, 2006 by President Bush) after Senators Bayh and Lugar sent a letter to Senate Finance Committee Chairman Charles Grassley (R-IA) and Ranking Member Max Baucus (D-MT) urging the Committee to take action to help prevent tragedies like the infant deaths that occurred at an Indianapolis hospital in September of 2006.

11. HR 6111 Tax Relief and Health Care Act of 2006 THE BENEFITS OF THIS LEGISLATION “The inclusion of hospital quality reporting requirements in this bill gives patients the information they need to better protect themselves and their families from medical errors by requiring hospitals to report whether they are meeting established safety standards,” Senator Bayh said. “By creating incentives for hospitals to use the latest technology to prevent mistakes, we will be able to significantly reduce the number of costly and tragic medical errors in Indiana and nationwide” (Dick, 2006).

12. Legislation & Safety “While addressing the problem of medication errors will require a multi-faceted approach, this is a vital first step,” said Senator Lugar. “The adoption of this measure will encourage hospitals to develop safety measures designed to prevent medication errors, which in turn will save lives” (Dick, 2006).

13. Nurse Responsibilities: Our Role in Safe Practice When discussing medication errors, it is important to reflect back to the Nursing Code of Ethics. Every part of the Code of Ethics relates to medication errors in some way. As nurses, it is our responsibility to uphold these ethics with which we have based our practice (Banning, 2011).

14. Specific Parts of the Code of Ethics that relate directly to this Ethical Dilemma include: “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient” (American Nurses Association, 2009).

15. Nursing Code of Ethics (continued) These specific parts of the Code of Ethics are important in this particular situation. The medication error occurred at the dispensing stage. Therefore, this medication error was not the fault of a nurse. However, this error was caught by the nurse caring for this patient. The nurse and student nurse in this situation upheld their duty and commitment to the Nursing Code of Ethics. They promoted health, advocated for the patient, and protected the wellbeing of the patient and the patient’s unborn child. The nurse and student nurse also made sure that her primary commitment was to the patient and the patient’s wellbeing. They both practiced with compassion and respect towards her patient as well.

16. Legal Ramifications Negligence is conduct below the standard of care for a “reasonable professional.” The claim would state that the nurse failed to verify the accuracy of the medication before administering it. will state that the nurse failed to adequately validate the right medication and in turn deviated from the expected standard of care. Since the nurse was an employee of the hospital, the hospital would be vicariously liable for the actions of the nurse employee (Potter & Perry, 2009).

17. Legal Ramifications(continued) Other professionals and/or employees or apparent agents of the hospital could also be “joined” in the lawsuit. For a plaintiff to have a successful negligence case in court, four essential elements are required: (1) a doctor-patient or professional relationship has to exist between the patient and the health care professional (i.e., MD, RN, Pharmacist ). This relationship ensures that the professional owes a duty of “reasonable care” to the patient. (2) The conduct of the professional had to be below the standard of care. (3) The patient was injured (damages), and (4) the action(s) (or inactions) that constituted the breach of duty was the “proximate cause” of the patient's injuries (Dick, 2006).

18. Legal Ramifications(continued) If this medication would have been given to the patient, she would have had a potential lawsuit against the hospital, the pharmacist and the nurse involved since there was a breach in duty.

19. Dilemma Discussion The ethical dilemma in this scenario was a medication error. The medication error occurred during the dispensing stage. This error was caught when the patient arrived at the hospital for 24-hour observations due to extremely high blood pressures. The patient was supposed to be taking Labetalol, a beta-blocker, which was prescribed for this patient due to high blood pressure.

20. Dilemma Discussion(continued) However, the prescription the patient received was for Tegretol. Tegretol is a medication used for the treatment of seizures. This medication is also a category D for pregnancy. According to Davis’s Drug Guide for Nurses Eleventh Edition, Category D medications used during pregnancy “have demonstrated a risk to the fetus” (Deglin, & Vallerand, 2009) Not only was the patient at risk from increasingly high blood pressures, but the fetus was also put at risk with this medication error.

21. Dilemma Discussion (continued) The medication error was realized with the pharmacy report. The medication on the pharmacy report did not match up with the medication the patient stated she was taking. Luckily, the patient had brought the medication bottle with her to the hospital. The student nurse had written down the medication directly from the label. When the pharmacy report came back and there was some discrepancy, the nurse resorted to the label on the bottle to ensure that an error had occurred. As soon as the medication error was confirmed, the medication bottle was held at the nurses station with a patient label on it. The on-call physician was also notified. The physician stated that the medication needed to be stopped immediately, and that Labetalol was to be ordered for a morning dose. The physician also stated that she would be in in the morning to speak with the patient about the error.

22. Medication Errors & Prevention Even though this medication error was caught prior to administering it to the patient, what could have been done to prevent this type of error? As a nurse, we have a responsibility to protect the patient. We cannot assume that someone else on the interdisciplinary team never makes errors. Even though a physician prescribes a medication, then the pharmacist fill the prescription, the nurse is the final health care professional to verify the 6 rights of medication administration. By educating our patients about their medications of side-effects, purpose and even what the medication looks like can involve the patient as an active participant in their healthcare.

23. Preventing this Ethical Dilemma(continued) It is time to recognize that health care is a team activity. Practicing medicine, nursing, and pharmacy is too complicated for health care professionals to be able to carry all required information in their heads. Acknowledgment by all health care professional that a problem with medication errors exist. This means reporting errors, analyzing errors, and redesigning faulty systems. A change in thought that reported errors can help in the future to prevent errors (Banning, 2011).

24. Patient Teaching With prevention being the key to medication errors, patient teaching is extremely important. Some things to teach patients about medications: How to take the medication. When to take the medication. Why the medication needs to be taken (what was the medication prescribed for?) The name of the medication and what it should look like. Teaching the patient what the medication should look and both the generic and brand name could have prevented the medication error discussed in the presentation.

26. The right dose

27. The right route

28. The right client

29. The right medication

30. The right documentation http://www.youtube.com/watch?v=uUeQJPhFnT4

31. The Right Medication In the ethical dilemma discussed, this is the “Right” that was wrong. Again, the error occurred at the dispensing stage, but had the pharmacy that dispensed the medication double or even triple checked the written prescription with the medication they were dispensing, this error could have been prevented.

32. Impact on Nursing After committing an error, nurses feel incompetent in their ability to safely and accurately administer medication. Due to disciplinary actions and possibly legal ramifications, nurses hesitate to report medication errors that did not cause any harm to the patient According to a study, nurses suffered from guilt and embarrassment when medication errors occurred and this resulted in some of the nurses leaving the profession altogether; this only contributes to the nursing shortage that we already face (Agyemang & While, 2010).

33. This and all medication errors can be prevented. It is important for nurses to advocate for their patient’s when administering medications. One way to advocate for the patient is use the six rights of medication administration. It is also important for the nurse to check two client identifiers prior to administering medications. The nurse administering the medication needs to be sure to that the client needs to take the medication by assessing the patient prior to administration. It is also important to question doses of medications, whether too large or too small.

34. Conclusion It is also important for the nurse to teach the patient about the medication they will be taking. The patient needs to understand why they are taking the medication and how to take it. The patient should also be able to recognize the medication to ensure it right. If a medication error does occur, it is important to “report all medication errors, including those that do not cause obvious harm or immediate harm or near misses” (Potter & Perry, 2009). Medication errors do occur, but it important to learn from these errors to prevent them from happening again.

35. References Agyemang, R., & While, A. (2010). Medication errors: Types, causes and impact on nursing practice. British Journal of Nursing (BJN), 19(6), 380-385. American Nurses Association (2011). Code of ethics for nurses with interpretive statements. Nursing World: Code of Ethics. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx Banning, M. (2011). How to avoid medication errors on your drug round. Nursing & Residential Care, 13(3), 129-131. Deglin, J. & Vallerand, A. (2009). Davis’s drug guide for nurses (11th ed.).Philadelphia, PA: F. A. Davis Company. Dick, G. (2006). Congress passes legislation to prevent medication errors. Inside Indiana Business. Retrieved from http://www.insideindianabusiness.com/newsitem.asp?ID=20906#middle Kaufman, M. (2006). Medication errors harming millions, report says. The Washington Post. Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html Potter, P. A., & Perry, A. G. (2009).Fundamentals of nursing (7th ed.). St. Louis, MI: Elsevier Mosby.

36. Project Distribution SPECIFIC MEMBER RESPONSIBILITIES & CONTRIBUTIONS Deborah McCray Provided recent research and collected data on different types medication errors and its impact on modern nursing practice. Katie Poindexter Provided research for the following: legislation, legal aspects & preventative methods regarding medication errors. Edited powerpoint, collaborated with the discussion, summary and conclusion of the ethical dilemma at hand & developed a pamphlet for prospective patients. Brittany Miller Organized and divided workload among group members; set deadlines for timely submission. Provided research regarding responsibility of nurses in medication errors and compiled the rough draft of presentation; established summary, conclusion and contributed in discussion. Inna Osipov Collected significant statistics related to medication errors, prepared graphs depicting the data; edited and made thorough revisions to the powerpoint, cited references in the proper APA formatting for a comprehensive reference page, incorporated appropriate illustrations for an appealing visual presentation, ensured transitional flow and correct grammar of the content.

37. Direct links:Web References Congress Passes Legislation to Prevent Medication Errors http://www.insideindianabusiness.com/newsitem.asp?ID=20906#middle How to Avoid Medication Errors on Drug Rounds http://proxy.uscupstate.edu:2555/ehost/pdfviewer/pdfviewer?sid=b9d83564-db3b-43bc-a864-2a38449b1256%40sessionmgr11&vid=4&hid=21 Medication Harming Millions, Report Says http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html Aiming High for the US Health System http://proxy.uscupstate.edu:2555/ehost/pdfviewer/pdfviewer?sid=a37e8570-a71c-49d3-b6ed-4cd25c43b6e1%40sessionmgr12&vid=10&hid=8 Code of Ethics for Nurses http://proxy.uscupstate.edu:2555/ehost/detail?vid=6&hid=21&sid=b9d83564-db3b-43bc-a864-2a38449b1256%40sessionmgr11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d